MEDICARE: CASSANDRA JEAN GAUDETTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	106S00000X	OTHER	MI	WORK

General Provider Information

NPI Number	:	1346739091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSANDRA JEAN GAUDETTE

Provider Business Mailing Address
First Line	:	1650 WELCOME AVE
Second Line	:
City	:	NATIONAL CITY
State	:	MI
Zip	:	48748-9436
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 WELCOME AVE
Second Line	:
City	:	NATIONAL CITY
State	:	MI
Zip	:	48748-9436
Country	:	US
Telephone Number	:	306-367-1665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2018
Last Update Date	:	05/08/2018

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Directions to “ CASSANDRA JEAN GAUDETTE ” Practice Location

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